Category: tools for health care workers

A commissioned article in Lancet Infectious Diseases on July 9, 2017 highlights some of the major issues and challenges facing us in the growing global epidemic of sexually transmitted infections (STI). Authors Prof Mabhus Unemo et al summarise the key issues as follows:

WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research.

In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control.

Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease.

The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials.

Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches.

Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation.

Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.

Daily HIV medicine taken by men who have sex with men (MSM) reduces risk of HIV infection by 86% as was reported by Molina J-M, and colleagues in the ANRS Ipergay trial at the Conference on Retroviruses and Opportunistic Infections held in Seattle, USA in 2015 (23LB.).

Molina et al reported the final results of a three year study which randomised MSM who were negative for HIV to either take daily HIV prophylaxis with two anti-retroviral drugs in a single tablet immediately or deferred for 1 year.

The study showed that those taking the drugs on a daily basis have a 86% reduction in the risk of being infected by HIV than MSM not taking the drug (p=0.0001). The trial was stopped in October of 2014 and all participants in the deferred group were offered pre-exposure prophylaxis (PrEP)

The science is now clear: oral pre-exposure prophylaxis (PrEP) with a coformulation of tenofovir disoproxil fumarate and emtricitabine (Truvada) significantly reduces the risk of HIV infection among individuals at high risk of HIV infection.

The news that PrEP has shown consistent efficacy among those who take it as prescribed should be a cause for celebration, and galvanise action to ensure access to PrEP for those who could benefit the most. But almost 3 years since the US Food and Drug Administration approved tenofovir–emtricitabine for PrEP little is being done on implementation.

Background: In the United Kingdom there is an established and growing refugee population from Somalia. Despite this Somalis have remained absent from much of the official statistics largely because ‘Somali’ is rarely recognised as a distinct ethnic category. Little is known about the sexual health needs of this particular community but in terms of their broader health issues, Somalis are known to have a high level of need but low uptake of health care services (Carswell et al.2011).

Aims: Through the use of focus groups and individual interviews this study sought to explore the sexual health needs of the local Somali community by ascertaining from their perspective, what they know about sexual health services, the challenges that may prevent them taking up these services and how services could be adapted to best meet their needs.

Results: The study showed little knowledge of services, especially about sexual health, how to accessing services, issues relating to shame, stigma and taboo, the influence of gender, religious and cultural norms, the perceptions of young people, the language barrier lack of cultural awareness and sensitivity demonstrated by healthcare professionals.

Recommendations:

Urgent attention be given to raising awareness, amongst the Somali community, about local sexual health services and how they can be accessed.

Information about sexual health services be made available in a format that is accessible to the Somali refugee community, for example, via a CD, DVD or USB stick.

That public health professionals and health care practitioners make clear the concept of preventative screening, making explicit the value of screening and early diagnosis for infectious diseases including TB and HIV/AIDS.

Health practitioners and public health professionals exercise extreme sensitivity when discussing issues related to sexual health and well-being. Every effort must be made to gain the trust of the individual so that they are able to discuss their fears or concerns.

Public health professionals and health care practitioners receive appropriate training and education so that they are equipped with the necessary cultural understanding and skills when working with the Somali community.

That a proactive approach be taken to helping Somali refugees to attend a programme of induction that includes language classes.

That a register of trained interpreters, who understand medical terminology and who are trained to work with those who may have experienced rape and torture should be available for public health professionals and health practitioners. Telephone interpretation should also be made available during consultations.

The results of the study have been presented in international meetings and published in reputable international journals.

On May 8 2014 the UK Court of Appeal dismissed the appeal of David Golding against a 14 month prison sentence for transmitting herpes to his partner.

An Editorial in the BMJ by Emily Clarke an colleagues highlights the numerous and complicated issues that arise from this verdict including:

what constitutes grievous bodily harm,

how you determine that sexual transmission has occurred,

how serious is herpes infection, and

what this judgement means both for health care workers who advise and inform patients on the risks of transmission and on the infected individual and their duty of informing all partners of potential risk of transmitting an infection even during asymptomatic shedding.

The Editorial correctly highlights the dangers of criminalizing sexually transmitted infections and the various problems that arise from this judgement which was based on a law passed 170 years ago addressing totally unrelated issues and at a time when STI’s were not understood as they are today.

Lymphogranuloma venereum (LGV), previously predominantly a tropical disease, re-emerged in Western Europe in 2003, and has arguably now regained endemic status in many countries. It remains largely contained within in a population of men who have sex with men (MSM) with high rates of other sexually transmitted infections (STIs) including HIV, though a first female case was reported in Sexually Transmitted Infections in 2012.

Moreover, microbiological characteristic of LGV repeaters using surveillance data has convinced Rönn and colleagues that behaviour alone does not explain reinfection, which they see as related to centrality in sexual networks.

Together these four articles add important information on the clinical presentation, epidemiology and treatment of LGV in MSM.

The March issue of the journal STI included an article by Sonia Fernandez-Balbuena and colleagues in Madrid which demonstrated that offering HIV testing on the street may allow a significant number of hard-to reach populations to offer themselves for HIV testing.

Of 7552 persons in various Spanish cities who were asked to full a brief questionnaire and offered HIV testing 3517 participants (47%) were first-time testers. These included 24% of men who have sex with men , 56% of exclusively heterosexual men and 60% of women. 22 undiagnosed HIV infections were detected with a global prevalence of 0.6% and 3.1% in MSM.

The authors concluded that their community programme attracted a substantial number of persons previously untested and particularly hard to reach, such as those with low education and MSM who were least involved in the gay community.

In their view a decisive in decisive factor for almost two of every three persons who had never been tested. was the visibility of the programme.